Table 4 EPA – Managing adult patients with acute chest pain

Justification

Chest pain is one of the most common presentations in the emergency department. The ability to conduct an accurate initial assessment of acute chest pain in adult patients is important in order to manage potentially life-threatening conditions.

In the emergency department, initial assessment of patients with acute chest pain requires the integration of multiple competencies and the ability to execute these in a busy clinical environment with multiple distractions.

Description

PGY1s must be able to assess, synthesise and prioritise key steps required in managing the care of an adult patient presenting with acute chest pain

They must have the ability to conduct a patient history and examination relevant to acute chest pain in a timely manner They must select, justify and interpret appropriate investigations and synthesise findings to formulate a working diagnosis. Interns must be able to commence initial therapeutic steps within guidelines applicable to the setting in which they work

They must have knowledge of causes, investigations and treatment options relevant to acute chest pain, and be able to recognise typical presentations of life-threatening diseases

PGY1s must also have the ability to recognise the signs and symptoms of a critically ill patient, and seek supervisory assistance with appropriate urgency

Link with ACFJD competencies

Clinical management – Safe patient care (Systems; Radiation safety); Patient assessment (History and examination; Problem formulation; Investigations; Referral and consultation); Emergencies (Assessment; Prioritisation); Patient management (Management options)

Communication – Patient interaction (Respect); Managing information (Written); Working in teams (Team structure; Case presentation)

Professionalism – Doctor and society (Professional standards); Professional behaviour (Professional responsibility; Time management; Personal well-being)

Skills and procedures – General (Measurement; Interpretation of results; Intravenous; Diagnostic); Cardiopulmonary

Clinical problems and conditions – Circulatory

Required knowledge, skills and attitudes

Knowledge

Demonstrates knowledge of chest pain causes

Demonstrates knowledge of signs and symptoms indicating patient is critically ill

Demonstrates knowledge of differential diagnoses related to chest pain, such as aortic dissection, pulmonary embolism, and myocardial infarction

Demonstrates knowledge of relevant investigations and treatment options for chest pain

Demonstrates knowledge of local guidelines in managing patients with chest pain (such as chest pain pathways)

Skills

Recognises signs of critical illness and can ask for help when needed with appropriate urgency

Takes a focused, relevant and succinct patient history in a timely manner

Performs a relevant and focused physical examination, including vital signs

Synthesises information to formulate provisional diagnosis

Performs procedural skills (venepuncture, cannulation)

Selects, requests and can justify relevant investigations (ECG, chest x-ray, blood tests)

Interprets relevant investigations (ECG, chest x-ray, blood tests)

Recognises abnormal results from investigations (ECG, chest x-ray, blood tests)

Simple pain management within appropriate guidelines for the setting

Formulates and can justify initial management plan

Maintains accurate and thorough documentation

Presents case clearly and succinctly to senior doctors and other staff

Attitudes

Adheres to professional standards

Aware of own limitations and asks for help appropriately

Respects patient privacy and confidentiality

Treats patients courteously and respectfully

Respects other health professional team members

Behaves in ways to mitigate the personal health risks of emergency medicine, such as fatigue and stress

Sources of information to assess progress

This EPA is continuously assessed during clinical supervision of PGY1s using direct observation, structured interviewing, case presentation and multi-source feedback.

Entrustment and supervision scale

Supervision of PGY1s is required with the supervisor present in the emergency department. However, the intensity of supervision varies according to the individual PGY1’s ability to perform the EPA. The 3 levels of decreasing intensity of supervision reflect the levels of entrustment.

Level 1: Direct active – Full supervision at bedside. After the supervisor’s initial assessment of the patient, the PGY1 assesses the patient with regular prompting and feedback from the supervisor.

Level 2: Indirect active – Partial supervision within line of sight. Supervisor pre-prompts PGY1 to assess the patient. The PGY1 reports back his or her assessment of the patient to the supervisor.

Level 3: Passive – Full entrustment with the supervisor present in the emergency department. The supervisor entrusts the PGY1 to initiate assessment of the patient and report back his or her findings with minimal prompting and feedback.

Estimated stage of training when level 3 (Passive) is to be reached

End of the emergency medicine rotation in the first year of GME training (PGY1)

Basis for formal entrustment decisions

The following activity will be entrusted at level 3 when the supervisor is confident that the PGY1 has the knowledge, skills and attitudes to perform the activity at an acceptable standard and that the intern knows when to ask for help in a timely manner.